Give a consise short note on surviving sepsis guidelines for dnb anaesthesia exam
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I now have comprehensive data from the full SSC 2026 guidelines. Let me write the concise exam-focused note.
Surviving Sepsis Campaign (SSC) 2026 Guidelines - Short Note for DNB Anaesthesia Exam
Source: SSC International Guidelines for Management of Sepsis and Septic Shock 2026 (Prescott HC et al. Critical Care Medicine, April 2026)
Definition (Sepsis-3)
- Sepsis: Life-threatening acute organ dysfunction due to infection
- Septic shock: Subset with circulatory dysfunction requiring vasopressors to maintain MAP ≥65 mmHg + serum lactate >2 mmol/L despite adequate fluid resuscitation (mortality >40%)
SCREENING & EARLY MANAGEMENT
| # | Recommendation | Strength |
|---|---|---|
| 1 | Performance improvement program with sepsis screening, SOPs, and QI strategies | Strong |
| 2 | "Code sepsis" / sepsis huddle protocol | Conditional |
| 3 | Prehospital ambulance screening tool | Conditional |
| 4 | NEWS, NEWS2, MEWS, or SIRS over qSOFA as single screening tool | Strong |
| 5 | Sepsis is a clinical diagnosis - cannot rule in/out by single biomarker | Good practice |
| 7 | Blood cultures before antibiotics (but don't delay antibiotics) | Strong |
| 8 | Measure blood lactate | Conditional |
| 9 | Sepsis/septic shock = medical emergency, treat immediately | Good practice |
INITIAL RESUSCITATION
| Recommendation | Detail | Strength |
|---|---|---|
| IV fluids | At least 30 mL/kg crystalloid in first 3 hours (use IBW if BMI >30) | Conditional |
| Vasopressor timing | Fluid bolus first, then vasopressor if hypotension persists. Concurrent if unstable | Conditional |
| Peripheral vasopressors | Start peripherally rather than delay for central access | Conditional |
| MAP target | 65 mmHg (initial target for all); 60-65 mmHg for patients ≥65 years | Strong / Conditional |
| ICU admission | Within 6 hours for patients requiring ICU | Conditional |
INFECTION MANAGEMENT
Antibiotic Timing:
- Septic shock (possible/probable/definite): Antibiotics immediately, ideally within 1 hour - Strong
- Probable/definite sepsis without shock: Antibiotics immediately, within 1 hour - Strong
- Possible sepsis without shock: Rapid assessment; administer within 3 hours if infection likely - Conditional
- Low likelihood of infection, no shock: Defer antibiotics, monitor closely - Conditional
Source control: Evaluate rapidly; perform within 6 hours of diagnosis - Conditional
Antibiotic Principles:
- Prolonged infusion of beta-lactams (after loading dose) over bolus - Strong (high certainty - BLING III data)
- De-escalation when microbiological diagnosis available - Strong
- Shorter duration over longer duration (adequate source control) - Conditional
- Procalcitonin + clinical evaluation to guide antibiotic discontinuation - Conditional
- Empiric antifungal: suggest against routine use (consider in high-risk: immunosuppression, prolonged abx, intra-abdominal source) - Conditional
- Empiric anaerobic coverage only with specific risk factors (intra-abdominal, necrotizing fasciitis, head-neck) - Conditional
- SDD (selective decontamination of digestive tract) in mechanically ventilated patients in low-MDR resistance settings - Conditional
HEMODYNAMIC MANAGEMENT
Vasopressors:
- Norepinephrine (NE) = first-line vasopressor - Strong
- NE preferred over vasopressin, angiotensin II - Conditional
- Add vasopressin when escalating NE doses - Conditional (moderate evidence)
- Add epinephrine if inadequate MAP on NE + vasopressin - Conditional
- Septic shock + cardiac dysfunction: NE or epinephrine (either) - Conditional
- Terlipressin: suggest against - Conditional
- Methylene blue (refractory shock): insufficient evidence
Inotropes (cardiac dysfunction + persistent hypoperfusion):
- Use inotropes - Conditional
- Dobutamine + NE or epinephrine alone - Conditional
- Levosimendan: suggest against - Conditional
Fluid Type:
- Crystalloids = first-line - Strong
- Balanced crystalloids (Ringer's) over 0.9% saline - Conditional (exception: TBI - use saline)
- Albumin: suggest against routine use; consider in large crystalloid volumes or cirrhosis - Conditional
- Starches: strongly against - Strong (high certainty)
- Gelatins: suggest against - Conditional
Fluid Resuscitation After Initial 30 mL/kg:
- Liberal vs restrictive: either, individualized - Conditional
- Use dynamic measures (PPV, SVV, passive leg raise, stroke volume) to guide further fluids - Conditional
- Serial lactate measurements to guide resuscitation - Conditional
- Capillary refill time as adjunct to other perfusion measures - Conditional
RESPIRATORY SUPPORT
| Intervention | Recommendation | Strength |
|---|---|---|
| Oxygen targets | Titrate FiO2; most use SpO2 90-96% | Conditional |
| HFNC over conventional O2 (PaO2/FiO2 <200) | Suggest HFNC | Conditional |
| HFNC over NIPPV as initial therapy | Suggest HFNC | Conditional |
| Awake proning (non-intubated) | Suggest trial | Conditional |
| Low tidal volume 6 mL/kg IBW (ARDS) | Recommend | Strong (high certainty) |
| Non-ARDS mechanical ventilation | 6-8 mL/kg IBW | Conditional |
| Plateau pressure ≤30 cmH2O (ARDS) | Recommend | Strong |
| Higher PEEP (moderate-severe ARDS) | Suggest | Conditional |
| Incremental PEEP titration strategy | Recommend against | Strong |
| Prone ventilation >12 hr/day (moderate-severe ARDS) | Suggest | Conditional |
| NMBA: intermittent bolus over continuous infusion | Suggest | Conditional |
| VV-ECMO (severe ARDS, conventional MV fails) | Suggest (experienced centers) | Conditional |
ADJUNCTIVE THERAPIES
| Drug | Recommendation |
|---|---|
| IV corticosteroids (septic shock) | Suggest use - Conditional. Hydrocortisone 200 mg/day × 7 days |
| IV Vitamin C | Suggest against |
| IV Immunoglobulin | Suggest against |
| Blood purification (hemoperfusion, plasmapheresis, high-dose HF) | Suggest against |
| Polymyxin B hemoperfusion | Suggest against |
| Vitamin D | Suggest against (for sepsis treatment) |
| Antipyretics | Suggest against (for improving outcomes; OK for symptom relief) |
| Probiotics | Suggest against |
| Beta-blockers | Suggest against |
ADDITIONAL SUPPORTIVE CARE
| Intervention | Recommendation | Strength |
|---|---|---|
| Stress ulcer prophylaxis (PPI) in those with GI bleed risk factors | Suggest | Conditional |
| Restrictive blood transfusion | Recommend | Strong |
| Early enteral nutrition (within 72 h) | Suggest | Conditional |
| Insulin: initiate at glucose ≥180 mg/dL (10 mmol/L) | Recommend | Strong |
| RRT: against routine use without definitive indication | Suggest against | Conditional |
| Continuous or intermittent RRT (when needed): either | Suggest | Conditional |
| NaHCO3: against for hemodynamics/vasopressor reduction | Suggest against | Conditional |
| NaHCO3: use if pH ≤7.2 + AKI (AKIN 2-3) | Suggest | Conditional |
| VTE prophylaxis with LMWH (unless contraindicated) | Recommend | Strong |
| Pharmacological VTE prophylaxis alone (over combined mechanical) | Suggest | Conditional |
| Active fluid removal (post-acute resuscitation phase) | Suggest | Conditional |
GOALS OF CARE
- Discuss goals of care with patient/family - Good practice
- Address goals within 72 hours - Conditional
- Principles of palliative care should be integrated when appropriate - Good practice
- Against routine formal palliative care consultation for all - Conditional
KEY EXAM POINTS TO REMEMBER
- Hour-1 bundle: Blood cultures, lactate, 30 mL/kg fluids, broad-spectrum antibiotics, vasopressors if hypotensive
- Antibiotics: within 1 hour for septic shock; within 1 hour for probable/definite sepsis; within 3 hours for possible sepsis
- MAP target: 65 mmHg (initial). For age ≥65 years: 60-65 mmHg (new in 2026)
- Vasopressor order: NE → add vasopressin → add epinephrine
- Crystalloids first; balanced > normal saline; strongly against starches
- Prolonged beta-lactam infusion: strong recommendation (upgraded to strong in 2026 based on BLING III)
- Low tidal volume 6 mL/kg IBW for ARDS (strong, high certainty)
- Corticosteroids for septic shock: hydrocortisone 200 mg/day (conditional)
- Insulin: start at glucose ≥180 mg/dL
- LMWH for VTE prophylaxis (strong)
- NEWS/NEWS2/MEWS/SIRS preferred over qSOFA for in-hospital screening (strong - new in 2026)
- HFNC preferred over conventional O2 and NIPPV for acute hypoxemic respiratory failure (new in 2026)
- SDD: new conditional recommendation in low-MDR settings
Note: This note is based on the SSC 2026 Guidelines (April 2026, Critical Care Medicine), which is the most current version of the guidelines at the time of writing. Key changes from 2021 include: MAP 60-65 for elderly, NEWS over qSOFA made strong, prolonged beta-lactam infusion upgraded to strong, HFNC recommendations formalized, SDD added, and several new adjunctive therapy recommendations.
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